Angel Care Home Health Services Inc.

“Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient’s mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient’s risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure the patients’ plan of care was complete and included all the required elements including a description of the patient’s risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors for 5 (Patients’ # 2, 3, 4, 6 and 7) of 7 records reviewed. These failures placed patients at risk of a decline in their health status and subsequent emergency room visits and hospital re-admissions. Findings include: Patient #2-review of Patient #2 revealed a plan of care dated 4/6/24 through 6/4/24 with a start of care of 10/14/22. The plan of care was electronically signed by the Administrator/Supervising Nurse on 5/27/24 with primary diagnosis of hypertensive heart disease (a group of heart problems that can develop when high blood pressure is left unmanaged over time) with heart failure (a serious condition that occurs when the heart can’t pump enough blood to meet the body’ needs). The plan of care did not include the patient risk factors for emergency department visits or hospital readmissions. Patient #3-review of Patient #3 revealed a plan of care dated 10/16/22 through 12/14/22 with a start of care of 2/18/22. The plan of care was electronically signed by the Administrator/Supervising Nurse on 10/11/22 with primary diagnosis of hypertensive heart disease (a group of heart problems that can develop when high blood pressure is left unmanaged over time) with heart failure (a serious condition that occurs when the heart can’t pump enough blood to meet the body’ needs). The plan of care did not include the patient risk factors for emergency department visits or hospital readmissions. Patient #4-review of Patient #4 revealed a plan of care dated 10/16/22 through 12/14/22 with a start of care of 2/18/22. The plan of care was electronically signed by the Administrator/Supervising Nurse on 10/11/22 with primary diagnosis of type 2 diabetes mellitus (your body doesn’t make enough insulin or doesn’t use insulin well) with diabetic poly neuropathy (a type of nerve damage that can occur if you have diabetes). The plan of care did not include the patient risk factors for emergency department visits or hospital readmissions. Patient #6-review of Patient #6 revealed a plan of care dated 7/31/22 through 9/28/22 with a start of care of 8/5/21. The plan of care was electronically signed by the Administrator/Supervising Nurse on 7/27/22 with primary diagnosis of hypertensive chronic kidney disease (a condition that occurs when high blood pressure damages the kidneys) with (when your kidneys are severely damaged and are no longer filtering waste from your blood). The plan of care did not include the patient risk factors for emergency department visits or hospital readmissions. Patient #7-review of Patient #7 revealed a plan of care dated 2/2/22 through 4/2/22 with a start of care of 8/6/21. The plan of care was electronically signed by the Administrator/Supervising Nurse on 1/31/22 with primary diagnosis of essential (primary) hypertension (high blood pressure that doesn’t have a known cause). The plan of care did not include the patient risk factors for emergency department visits or hospital readmissions. An interview was conducted on 10/11/24 at 10:25 am with the Administrator/Supervising Nurse. Surveyor reviewed the agency policy on the Plan of Care, PC.35 with the Administrator/Supervising Nurse, in that the policy stated the plan of care must include patient risks for emergency department visits and hospital re-admissions. Surveyor reviewed that the plans of care for Patient’s #2, 3, 4, 6, and 7 did not include the risks for emergency department visits or re-hospitalizations. The Administrator/Supervising Nurse said, “It is on the OASIS. The software is not working right.” Agency policy PC.35 Plan of Care last reviewed on 5/2/24 read in part…” Procedure… III. A. The individualized plan of care must include the following, …12. A description of the patient’s/client’s risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors.”…”